Langeberg Municipal District of South
Africa: a Qualitative Study
by
Réna Isabel Kriel
Thesis presented in partial fulfilment of the requirements for the degree of Master of Science in the Faculty of Physiotherapy at Stellenbosch University.
Supervisor: Prof. Quinette Louw Co-Supervisor: Dr. Yolandi Brink
I
Declaration
By submitting this thesis electronically, I declare that the entirety of the work contained therein is my own, original work, that I am the sole author thereof, that reproduction and publication thereof by Stellenbosch University will not infringe any third party rights and that I have not previously in its entirety or in part submitted it for obtaining any qualification.
Réna Kriel
Copyright © 2018 Stellenbosch University All rights reserved
II
Abstract
Background: In order to improve the effectiveness of spinal health educational programs, in
an effort to improve spinal behaviour of children and adolescents, research is needed to identify and explore the reasons why changes are stunted. To assist with the development of spinal health promotion strategies, the current perspectives and knowledge of different socio-economic societies and cultures need to be explored. Aim: The purpose of this study was to explore what the perspectives of learners (children and adolescents), teachers and parents/guardians were on the spinal health of learners in the Langeberg Municipal District of South Africa. Methodology: A descriptive qualitative case study design with an interpretative and phenomenological approach was used. Ninety-three participants were purposively sampled and participated in In-Depth Interviews (IDI’s) or Focus Group Discussions (FGD’s). An interview schedule guided the discussions. All IDI’s and FGD’s were recorded and transcribed. Analysis was done from the transcripts and inductive reasoning was used to explore the phenomena of spinal health in learners. Transcripts were coded based on initial and subsequent emerging themes. Results: A total of nine IDI’s and 11 FDG’s were conducted with 93 participants from 14 different schools. Three main themes emerged from the data: Barriers associated with self-care of spinal health; Facilitators to assist with Spinal Health and Back care; and Proposed Interventions for Spinal Health Barriers. Conclusion: The barriers emphasized by participants showed that there were problems with the spinal health of learners that needed to be addressed. The facilitators showed that barriers could be addressed but that the current facilitators weren’t sufficient. The participants’ proposed interventions gave plausible solutions to address the learners’ spinal health barriers and to enhance the effectiveness of the facilitators. Clinicians and therapists should consider knowledge, behaviour and exercise when treating learners with LBP for a wholistic intervention. Further research is needed on the effectiveness of different delivery methods for different ages aimed at long term effectiveness. Future research should also focus on development and implementation of spinal health educational programs by pilot testing spinal health educational programs in South African Schools, including all grades.
III
Opsomming
Agtergrond: Ten einde die doeltreffendheid van werwelkolom
gesondheidsopvoedingsprogramme te verbeter, in 'n poging om spinale gedrag van kinders en adolessente te verbeter, is navorsing nodig om die redes te identifiseer waarom veranderinge verstom word. Om te help met die ontwikkeling van spinaal gesondheidsbevorderingstrategieë, moet die huidige perspektiewe en kennis van verskillende sosio-ekonomiese gemeenskappe en kulture ondersoek word. Doel: Die doel
van hierdie studie was om die perspektiewe van leerders (kinders en adolessente), onderwysers en ouers/voogde oor die spinale gesondheid van leerders in die Langeberg Munisipale Distrik van Suid-Afrika te ondersoek. Metodologie: ʼn Beskrywende kwalitatiewe gevallestudie ontwerp met ʼn interpretatiewe en fenomenologiese benadering is gebruik. Drie-en-negentig deelnemers was doelgerig gekies en het deelgeneem aan In-diepte Onderhoude (IDO) of Fokus Groep Gesprekke (FGG). ʼn Onderhoud skedule het die gesprekke gelei. Alle IDO en FGG was opgeneem en getranskribeer. Analise was vanaf die transkripsies gedoen en induktiewe redenasie was gebruik om die fenomene van spinale gesondheid in leerders te ondersoek. Resultate: ‘n Totaal van nege IDO en 11 FGG was uitgevoer wat 93 deelnemers van 14 verskillende skole ingesluit het. Drie hoof temas het uit die data na vore gekom: Hindernisse wat verband hou met selfsorg van spinale gesondheid; Fasiliteerders wat help met spinale gesondheid en rugversorging; en Voorgestelde intervensies vir spinale gesondheids hindernisse. Gevolgtrekkings: Die struikelblokke wat deur deelnemers beklemtoon is, het getoon dat daar probleme met die ruggesondheid van leerders was wat aangespreek moet word. Die fasiliteerders het getoon dat hindernisse aangespreek kan word, maar dat die huidige fasiliteerders nie voldoende was nie. Die deelnemers se voorgestelde intervensies het geloofwaardige oplossings gegee om die leerders se spinale gesondheids hindernisse te hanteer en die effektiwiteit van die fasiliteerders te verbeter. Klinici en terapeute moet kennis, gedrag en oefening oorweeg wanneer leerders met lae rug pyn behandel word vir 'n holistiese ingryping. Verdere navorsing is nodig om die doeltreffendheid van verskillende onderrigmetodes vir verskillende ouderdomme wat op langtermyn doeltreffendheid gemik is. Toekomstige navorsing moet ook fokus op die ontwikkeling en implementering van werwelkolom gesondheidsopvoedkundige programme deur werwelkolom gesondheidsopvoedings programme in alle grade in Suid-Afrikaanse skole te toets.
IV
Acknowledgements
I would like to extend my sincere gratitude to the following persons for their contribution to this research project:
My supervisor, Prof. Quinette Louw, who provided continued support and guidance,
encouraging me to improve the quality of my work to the very end;
My co-supervisor, Dr. Yolandi Brink, who’s input and guidance I valued greatly; Mr. Dominic Fisher, for the times we discussed my findings, giving me new
perspectives and for your assistance with data checking;
The learners, teachers, parents and principals of the schools that participated in this research project, without whose participation this project would not have been possible;
The Physiotherapy Division of Stellenbosch University for your support;
The National Research Foundation (NRF) of South Africa for their financial support of this project;
My extended family and friends who were always interested in what I was doing and giving me loving encouragement and support;
My aunt, Charlie, for her assistance in the final phase of this project that calmed my nerves considerably;
Most importantly my parents, Jacques and Phyllis, for their continued love,
patience, encouragement and support throughout this time that made it possible for me to accomplish this dream;
V
Table of Contents
Declaration ... I Abstract ... II Opsomming ... III Acknowledgements ...IV Table of Contents ...V List of Figures ...VII List of Tables ...VII List of Abbreviations ...VIICHAPTER 1: Literature Review
... 11.1. Introduction ... 1
1.2. Child and adolescent LBP’s contribution to the world population ... 1
1.3. Low Back Pain in Children and Adolescents ... 1
1.4. LBP risk factors and schools as exposure environments ... 3
1.4.1. Relative backpack weight ... 3
1.4.2. Ergonomics and Posture ... 4
1.4.3. Physical activity level and LBP ... 5
1.4.4. Spinal health knowledge ... 5
1.5. LBP impact on an adolescent individual ... 6
1.6. Parental influences on spinal health and back care ... 7
1.7. School based interventions to address LBP ... 8
1.8. Summary ... 9
CHAPTER 2: Manuscript ... 10
2.1. INTRODUCTION ... 10 2.2. METHODOLOGY ... 13 2.2.1. Study Setting ... 13 2.2.2. Study Design... 132.2.3. Ethics and Permission ... 14
2.2.4. Researcher Characteristics and Background... 14
2.2.5. Sample Selection ... 14
2.2.6. Participant Recruitment ... 16
VI 2.2.8. Data Analysis ... 19 2.2.9. Trustworthiness ... 19 2.3. RESULTS ... 21 2.3.1. Demographic Data ... 21 2.3.2. Themes ... 22
2.3.2.1. Theme 1: Barriers associated with self-care of spinal health ... 22
2.3.2.2. Theme 2: Facilitators to assist with Spinal Health and Back care ... 34
2.3.2.3. Theme 3: Proposed Interventions for Spinal Health Barriers ... 39
2.4. DISCUSSION ... 47 2.5. CONCLUSION ... 55 2.6. ACKNOWLEDGEMENTS ... 56
CHAPTER 3: Summary ... 57
REFERENCES ... 60
APPENDICES ... 63
Appendix 1: WORK journal specifics for publication ... 63
Appendix 2: Ethics Approval ... 67
Appendix 3: Western Cape Education Department Approval ... 69
Appendix 4: Informed Consent Form for Principals... 70
Appendix 5: Informed Consent Form for Teachers... 73
Appendix 6: Informed Consent Form for Parents/Guardians ... 76
Appendix 7: Informed Consent Form for Parents of Learner Participants ... 79
Appendix 8: Assent Form for Learner Participants ... 82
Appendix 9: Transcript extracts ... 85
Appendix 10: Adapted questions for children ... 91
Appendix 11: Afrikaans Questions for IDI’s and FGD’s ... 91
VII
List of Figures
Figure 2.1: Langeberg Municipal District Map ... 133
List of Tables
Table 2.1: Selection Process ... 166 Table 2.2: Demographic Data ... 221 Table 2.3: District Schools and Learners ... 22
List of Abbreviations
IDI - In-Depth Interview FGD - Focus Group Discussion LBP - Low Back Pain
MSK - Musculoskeletal
NRF - National Research Foundation RBW - Relative Backpack Weight
1
CHAPTER 1: Literature Review
1.1. Introduction
This literature review provides an overview of low back pain (LBP) and back care amongst children and adolescents. The following electronic databases were searched: Cochrane, Google Scholar, PEDro, PubMed, and the Stellenbosch University electronic library database. Different combinations of the key terms “spinal health”, “back care”, “back pain”, “adolescent”, and “child” were used to search the databases. The database searches were conducted between March 2016 and October 2017 and relevant studies were obtained for inclusion in this literature review.
1.2. Child and adolescent LBP’s contribution to the world population
Musculoskeletal (MSK) disorders are the fourth greatest burden on the world population’s health.[1,2] LBP is the most prevalent MSK condition and the most common cause of disability worldwide.[1,2] Annually LBP contributes billions of dollars in medical expenditure to the economic burden, with adolescents making up 15% of the LBP population.[1] With back pain reported in childhood and adolescence being a significant indicator for back pain in adulthood[3-5], school based education of children and adolescents on the principles of back care are seen as a plausible way of reducing the burden caused by back pain.[6]
1.3. Low Back Pain in Children and Adolescents
LBP is a common cause of morbidity and disability worldwide affecting people of all ages.[1,2] Although the economically active stratum of the population is most affected, an increasing number of children and adolescents experience LBP.[1] The increase in child and
2
adolescent LBP could be due to school-going adolescents engaging in commercial activities after school to help ease the economic burden on their families.[7] However, this reason is only given for African countries and reasons for the increase in LBP amongst adolescents in high income countries may be different.[7-8]
The prevalence of adolescent LBP varies widely between countries ranging from 7 to 70%, depending on the study design and pain definitions.[7-10] In African countries, up to every second adolescent experiences back pain.[7] Research reporting on the prevalence of LBP amongst children is considerably less than for adolescent LBP. However, an estimated 15% of African children have experienced LBP at some stage of their life.[8]
There is inconsistent reporting of the difference between genders in terms of LBP prevalence among children and adolescents. Research shows either no difference between genders or a higher LBP prevalence in females.[5,7,9,11-12] The reason for the inconsistency could be attributed to very few studies reporting on the differences before and after the onset of puberty.[9] Only one study has differentiated between before and after onset of puberty identifying that LBP prevalence between genders are the same under the age of 10 years but differ after the onset of puberty.[9] LBP reported by females could then be related to menstruation and physique changes brought on by puberty and explain why adolescent females might have a higher LBP prevalence.[9] Females are at greater risk of LBP with the condition being reported earlier in females than males.[13] This could be attributed to females going through growth spurts due to hormonal changes at a younger age compared to males.[3,13-14] The reason for females being at greater risk could also be attributed to females carrying heavier backpacks than males or because of the stronger male physique when carrying equal backpack weights.[15] With several factors contributing to back pain, it
3
is not surprising to see such a wide prevalence range and potential gender differences in adolescent LBP.[8]
1.4. LBP risk factors and schools as exposure environments
Schools offer a range of exposures that may increase the risk of developing MSK disorders in children and adolescents.[3] These exposures included ergonomics of school furniture, unsafe backpack use, ergonomic risk factors, lack of exercise and low levels of specific back care knowledge.[3-4,7-8] These risk factors may contribute towards a range of multifactorial pathways. Despite this, parents and teachers’ main concern was the heavy backpacks being carried by learners to, at, and from school.[15] Adolescents’ most common perceived risk factors for back pain were bending activities, school bag weight and sitting for a prolonged period of time.[7] Spinal curvature, spinal misalignment and muscle spasms can be a result of postural changes caused by long-term backpack use.[15] With so many LBP risk factors, it is not surprising that there would be a difference of opinion about the most concerning factor.
1.4.1. Relative backpack weight
There is a great deal of literature on the relative backpack weight (RBW) of children and adolescents that may be associated with LBP. RBW is calculated as a percentage of the person’s body mass.[8,15] Measured RBW ranged from 14.4 to 22% depending on school type, day of the week, school grade and country.[8] Discrepancies for the recommended cut-off weight of backpacks ranged from 10-15% with 15% being widely recommended.[15-16] The difference between 10% and 15% was about 3kg which translated to between 1 and 2 school textbooks.[15] Backpacks weighing 15% of body mass in adolescents appeared to be too heavy to maintain a correct standing posture.[16] Adolescents who carried backpacks
4
weighing more than 10% reported back pain, while those who carried backpacks weighing below 10% did not.[15] Physical compensations such as forward leaning and postural alignment asymmetry were also seen when RBW exceeded 10%.[8] Younger and smaller learners were also at greater risk as they weighed less while carrying the same weight as older learners, which resulted in an increase in the RBW.[15] With back pain being reported when RBW exceeds 10% it would suggest that a 10% cut-off weight would reduce the risk of LBP more than the 15% cut-off weight.
1.4.2. Ergonomics and Posture
Poor ergonomics and posture is another school related factor that may be associated with MSK disorders such as back pain or discomfort.[9,14] Various spinal posture misalignments originate in childhood and adolescence due to the spine’s vulnerability during rapid MSK development.[3,14] Postural misalignments, such as forward head posture, kyphosis, lordosis and scoliosis are spinal conditions that can cause back pain.[17] Pain intensity is related to the severity of the MSK condition but even the slightest spinal misalignment from poor ergonomics or posture could be painful.[17]
Prolonged sitting, such as children and adolescents experience at school, is also associated with back pain.[8,14] Muscle fatigue due to prolonged sitting can cause back discomfort and pain that places children and adolescents at risk of back injury.[18] Also, passive flexion stiffness increases after one and two hours of sitting for males and females respectively.[18] As muscle fatigue and stiffness worsens the longer an individual sits, so too does the risk of developing back discomfort or pain.
In the modern technological age, children and adolescents spend an increasing amount of time sitting in front of a TV or computer, developing a static and passive lifestyle.[14,19] The
5
combined effects of such a lifestyle can lead to incorrect posture, in addition to inefficient and harmful movement patterns.[19] Adding to the negative effects of a sedentary lifestyle, school furniture that cannot adapt to a child’s rapid growth, negatively influences a child and adolescent’s ergonomics and posture in the classroom.[19] This problematic design of school furniture is not recognised by educational managers.[3] Ergonomics, posture and sitting duration influences spinal alignments which, when incorrect, can lead to back discomfort and pain.
1.4.3. Physical activity level and LBP
Children and adolescents who are physically over active and those who are minimally active are at greater risk of developing back pain.[8] Over active children and adolescents are at risk of overuse injuries while minimally active children and adolescents are at risk of injuries due to underuse of muscles.[8] There is, unfortunately, no evidence for specific over and underuse activities making it difficult to determine to what extent physical activity influences the risk of developing back pain.[8]
1.4.4. Spinal health knowledge
A lack of spinal health knowledge and inadequate instructions on spinal care during childhood and adolescence could result in poor postural habits.[3] These poor postural habits can subsequently lead to pain and structural skeletal deformities.[3] Children and adolescents were found to be the most lacking in knowledge relating to spinal anatomy, spinal pathology and maximum backpack weight.[3] A possible reason for this lack of knowledge could be due to the complexity of these topics, and that children and adolescents don’t fully comprehend the topics resulting in poor spinal health decisions
6
being made.[3] This suggests that proper education on spinal health is needed to address the lack of and incomprehensible knowledge of children and adolescents.
1.5. LBP impact on an adolescent individual
The impact of LBP on an individual is extensive, with individuals potentially being a burden to their families, having a decrease in independence and having less financial stability.[20] LBP can negatively impact an individual’s quality of life through partial and temporary decrease in the execution of daily activities.[9] Adolescent LBP has the greatest impact on an individual’s sport participation, bending activities, sitting and reaching up, while the impact on carrying a schoolbag in comparison is considerably lower.[13] Adolescent back pain is associated with higher RBW, reduced school attendance and scholastic functioning, reduced sports participation time and an increased use of chiropractic care.[9,14-15] Up to 16.1% of adolescents have reported missing school days due to back pain.[15] Lost school time can cause a decrease in academic performance and, depending on the severity of the LBP; an individual could potentially be forced to drop out of school.
The most significant negative impact of LBP is on the physical functioning and physical health of an individual.[9,14] The reason for LBP having such a negative impact was due to symptoms resulting in loss of function, attributed to the diminished performance in everyday activities.[9,20] LBP is also associated with reduced social interactions and psychological functioning.[9,14] Persons suffering from LBP were prone to avoiding social interactions, which resulted in damaged relationships.[20] Psychosocial functioning was affected by other individuals regarding LBP claims as unwarranted, especially when the complainant participated in activities while experiencing pain.[20] These claims were further delegitimized due to no visible injury or adequate diagnosis being given.[20] LBP impacts on
7
an adolescent individual’s education, physical capabilities as well as emotional wellbeing which reduce their quality of life.
1.6. Parental influences on spinal health and back care
Parents’ main concern regarding their children’s spinal health was the heavy backpacks that they had to carry.[15] Even though parents were concerned about the weight and size of their children’s backpacks, only a third of parents had checked the contents and 4% had weighed their children’s backpacks.[21] Significantly heavier backpacks were carried by children whose parents had never checked their backpacks’ content or weight.[21] Research had mostly focussed on adolescents’ backpacks when investigating spinal health, which gave a biased view of parental influences on the spinal health and back care of their children.
Parents also played a role in their children’s reporting and consequent treatment of LBP symptoms, irrespective of the symptoms’ severity.[13] There was no association between the severity of disability caused by LBP and health-care seeking behaviour in adolescents.[13] The reason for the poor health-care seeking behaviour could have been attributed to poor communication between parents and their children, due to perceived emotional overload.[8] It was also postulated that children and adolescents feared parental criticization and consequently didn’t report symptoms.[5,13] Even though LBP is common amongst adolescents, only 16.3% of parents were aware of their children’s LBP.[5] Treatment seeking behaviour also differed when two children, from different families, seemingly had the same symptoms.[8] One child might have been taken to a doctor while the other would have been told to wait and see what happened.[8] A possible reason for higher reported prevalence of adolescent LBP could then be attributed to them having parents who suffered from back pain.[8]
8
1.7. School based interventions to address LBP
Children and adolescents showed an increase in and retention of knowledge and ergonomic concepts from spinal health education into adulthood, without any fear-avoidance beliefs being reinforced.[3-4,6] Spinal health and back care educational programs had been presented at schools by physiotherapists, with sessions spread out over a few weeks.[4,6] These educational programs included sessions on basic anatomy and function of the spine; safe backpack use; good and bad postures; and how spinal problems could develop.[4,6] Children’s knowledge had also significantly improved after they were given a comic book on the subject of backs by their teachers, which showed that the use of pictures was effective as an educational tool.[10] Even though children’s knowledge showed significant improvement following educational programs, no significant changes in spinal health practices or self-efficacy were observed.[4,6] Obtaining theoretical knowledge on spinal health is the first step towards healthy spinal habits and back care for the prevention of back pain.[3]
Starting at a young age, children and adolescents need to be trained in ergonomics as part of the Physical Education curriculum, with increasing intensity and magnitude for greater effect.[10,19] To prevent child and adolescent back pain and discomfort, education needs to be paired with training of correct biomechanical functionality using movement.[19] Children and adolescents were capable of acquiring and comprehending correct movement patterns. The best solution to accomplish correct movement habits was through integrated programs comprised of balanced posture and exercises to improve physical fitness, body function, movement patterns, and ergonomic implications.[19] School furniture also has to be adaptable to children and adolescent’s needs in order to improve sitting posture.[10,19] It is
9
important to note that when adjustable furniture was provided to adults, it did not result in improved posture unless instruction manuals and regular reinforcements were provided.[3] To obtain the best results for behavioural changes, a combination of postural correction and exercise with theoretical knowledge has been advised.[10]
The effectiveness of interventions was not influenced by the age or gender of the children or adolescents.[10] There was, however, a disagreement on the effect of using outside agents or parents and teachers to perform interventions.[10] This disagreement could be due to the subjectivity and differences of children and adolescents. To conclude, children and adolescents do retain knowledge of spinal health education. However, the education programs need to be improved to be adaptable to any circumstance and be more effective in changing the spinal behaviour of children and adolescents.
1.8. Summary
From the literature we have a good understanding of how poor spinal health activities, lack of knowledge and poor ergonomics relate to back pain in children and adolescents, and that risk factors are greatly associated with school environments. With this knowledge in hand, it is unclear why there are so many different opinions about the spinal health of children and adolescents. Qualitative research can be used to explore and develop these theories and move towards explanations to improve the effectiveness of interventions.[22] To our knowledge there are no published qualitative studies to explore LBP and poor spinal health in schools.
10
CHAPTER 2: Manuscript
This manuscript shall be submitted to the WORK journal for publication. The specifics for publication are presented in Appendix 1.
2.1. INTRODUCTION
Low back pain (LBP) is a common cause of morbidity worldwide, affecting people of all ages.[1-2] Although the economically active stratum of the population is most affected, an increasing number of children and adolescents experience LBP.[1] The life-time prevalence of adolescent LBP varies widely between countries, ranging from 7 to 70% depending on the study’s research design and pain definition.[7,9-10,23] In African countries, up to every second adolescent experiences LBP.[7,12-13] The risk of LBP among African adolescents increases with chronological age and engagement in commercial activities.[7,12] Due to economic reasons, many school-going adolescents are forced to engage in after-school commercial activities which are believed to be the reason for the increase in adolescent LBP prevalence.[7] Even though non-specific LBP is common amongst adolescents, most parents remain unaware of the presence thereof.[13] It is postulated that children fear parental criticization and consequently don’t report symptoms.[13] During the day children and adolescents spend most of their time at school, which is an environment where they are exposed to spinal health risk factors.[24]
Schools are potential environments for children to develop musculoskeletal disorders, such as LBP, due to regular exposure to ergonomic risk factors.[3] Risk factors in schools for child and adolescent LBP have multifactorial influences including unsafe use of backpacks, ergonomic risk factors, lack of exercise and low levels of specific back care knowledge.[3-4,7] Ergonomic risk factors for spinal health include inadequate furniture, postures during
11
prolonged sitting periods and carrying heavy backpacks[3] while choosing the incorrect type of backpack, incorrect packing, and incorrect lifting and carrying of backpacks are seen as methods of unsafe backpack use.[4] Some of these school related spinal health risk factors can be modified by educating children and adolescents on back care[4,11], but the effectiveness of preventative interventions is affected by moderator variables such as teaching methods.[10] Risk factors at school can lead to spinal deformities and pain in children and adolescents.[3,14,18]
In South Africa children and adolescents spend a minimum of 5.5 hours per day at school, most of which is spent in awkward sitting positions.[25] Various spinal posture misalignments originate in childhood and adolescence due to the spine’s vulnerability during rapid musculoskeletal (MSK) development (growth spurts).[3,14] Postural misalignments, such as forward head posture, kyphosis, lordosis and scoliosis are spinal conditions that can cause back pain; the pain intensity is related to the severity of the condition.[17] Furthermore, muscle fatigue due to prolonged sitting can cause back discomfort and pain that places children and adolescents at risk of back injury.[18] Passive flexion stiffness increases after one and two hours of sitting for males and females respectively.[18] Back pain reported in childhood is a significant indicator for back pain in adulthood.[3-5] Currently there is no definition for spinal health or back care but these terms are used in literature as concepts pertaining to the prevention of back pain.[3-4,11]
Children and adolescents retain knowledge of spinal health education up to adulthood without fear-avoidance beliefs being reinforced.[3-4,6] Spinal health educational programs have been presented at schools by physiotherapists with sessions spread out over several weeks.[4,6] These educational programs included sessions on the basic anatomy and
12
function of the spine; safe backpack use; good and bad postures; and how spinal problems can develop.[4,6] Even though children’s knowledge showed significant improvement following educational programs, no significant changes in spinal health practices or self-efficacy were observed.[4,6] To obtain the best results for behavioural changes, a combination of postural correction and exercise has been advised.[10] To conclude, children and adolescents do retain knowledge of spinal health education, however, the education programs need to be improved for effectiveness.
In order to improve the effectiveness of spinal health educational programs, in an effort to improve spinal behaviour of children and adolescents, research is needed to identify and explore the reasons why changes are stunted. To assist with the development of spinal health promotion strategies, the current perspectives and knowledge of different socio-economic societies and cultures need to be explored. Qualitative research can be used to describe complex phenomena by initially exploring to develop theories and to move towards explanations.[22] Individuals directly and indirectly associated with the target population, children and adolescents, should have the greatest insights into the phenomenon. By explaining and clarifying events and individuals’ experiences, qualitative research can be used to complement quantitative research.[22]
To our knowledge there are no published qualitative studies to explore LBP and poor spinal health in schools. There is a lack of published research about child and adolescent spinal health in South African Schools. Also, research is needed to improve school based spinal health and preventative strategies. Knowledge of uniquely South African perspectives about spinal health of children and adolescents is necessary, due to the differences in educational systems, compared to other countries and to ensure that interventions are context specific.
13
The study aimed to explore what the perspectives of learners (children and adolescents), teachers and parents/guardians were on the spinal health of learners in the Langeberg Municipal District of South Africa. The objectives for the study were to explore and describe barriers and facilitators for the promotion of spinal health and to describe strategies and delivery methods to promote spinal health in schools. The findings of this study will help raise awareness of spinal health and help prevent child and adolescent LBP. The findings can also be used in conjunction with other studies’ results to improve on educational back care programs for learners.
2.2. METHODOLOGY
2.2.1. Study Setting
The study was purposively conducted in the rural region of the Langeberg Municipal District of the Western Cape, South Africa had a total population of 99’609 in 2013.[26] The district has 54 schools, excluding pre-schools, comprising of Combined (n=4), Intermediate (n=5), Primary (n=41) and
Secondary (n=4) Schools. Of the 54 schools in the district, only one was an independent private school. At the start of 2017 there were 18’325 Grade 1 to 12 learners enrolled in these schools.
2.2.2. Study Design
For this study, a descriptive qualitative case study design with an interpretative and phenomenological approach was used. The phenomenon that was explored in this study is
14
the learners, teachers and parents/guardians’ knowledge and perspectives about spinal health barriers, facilitators and plausible interventions for spinal health promotion in schools. The study made use of two qualitative methods, i.e. In-Depth Interviews (IDI’s) and Focus Group Discussions (FGD’s); for data collection.
2.2.3. Ethics and Permission
This study was approved by the Health Research Ethics Committee at Stellenbosch University (Ethics reference number S16/10/187) (Appendix 2) and was conducted according to the ethical guidelines and principles of the International Declaration of Helsinki. Permission to conduct the study in the Langeberg Municipal District’s schools was obtained from the Western Cape Education Department (WCED) (Appendix 3). All participants gave signed informed consent prior to being interviewed or participating in a discussion group (Appendix 4-6). In the case of learner participants, consent was obtained from the parents and assent was given by the learners (Appendix 7-8).
2.2.4. Researcher Characteristics and Background
The researcher underwent training in qualitative research methods for health sciences, which included interviewing skills, as preparation for data collection and analysis. This training was also used to pilot test the study’s interview schedule to ensure questions asked obtained the intended data. The researcher is a female physiotherapist who grew up in the district, which may have influenced the qualitative information obtained from the participants.
2.2.5. Sample Selection
The study population comprised of school administrators in the form of principals and teachers; learners; and parents or guardians. The key determining variables used for
15
selection of schools were the geographic region, including schools from all 5 towns in the district; school type, with Primary, Intermediate, Secondary and Combined Schools being included; and higher and lower socio-economic statuses by referring to the WCED’s registry of schools with and without school fees. Schools were purposively selected to ensure inclusion of all criteria. School characteristics were purposively omitted to ensure the anonymity of the participants.
Learners were selected by the researcher to be able to include at least one group from the Foundation (grades 1-3), Intermediate (grades 4-6), Senior Phases (grades 7-9) and Further Education Training (grades 10-12). Including learners from all education phases ensured ages ranged from 8 to 18 years. The gender of learners was dispersed equally between male and female on selection of the group. The learners were nominated by the class teacher, who was identified by the school principal as having the most interaction with the learners. The racial representation in the groups reflected the ethnic groups found in the specific schools. Learners with high and low academic standing, as ranked by the school, as well as learners participating and not participating in extramural activities were included.
Parents/guardians were selected by the researcher based on the educational phases of their children, ensuring exposure to all phases. All teachers from selected schools’ staff were eligible for inclusion in the study. This ensured that teachers of all ages, both sexes, and teaching in different educational phases were included. Principles had to have a minimum of 5 years’ experience as Principal of the selected school in order to be included in the study; this helped to ensure that the Principals’ knowledge was primarily related to the selected school. These selection criteria, as depicted in Table 2.1, ensured that a diversified set of participants was selected to participate in the study.
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Table 2.1: Selection Process
Town School School Type Phase* Grades Participant group
School Fees **
Town A
School A Primary 1-3 1-7 Teacher Yes School B Secondary 3-4 8-12 Teacher &
Parent No School C Primary 1-3 1-7 Parents No Town B School D Combined 1-4 1-12 Principal Yes 4 12 Learners Town
C School E Intermediate 1-3 1-8 Teachers No
Town D
School F Primary 1-3 1-7 Principal No School G Intermediate 3 8-9 Learners No School H Secondary 3-4 8-12 Teachers Yes School I Primary 2 6 Learners Yes School J Intermediate 1 3 Learners No
Town E
School K Secondary 4 11-12 Learners No School L Secondary 3-4 8-11 Parents Yes School M Primary 1-3 1-7 Principal Yes
2 4-5 Parents
School N Primary 1-3 1-7 Principal Yes
* 1=Foundation phase, 2=Intermediate Phase, 3 Senior Phase, 4=Further Education Training ** No school fees = school children exempt from school fees indicating a low socio-economic school
2.2.6. Participant Recruitment
Selected schools were contacted telephonically and appointments made with school principals. The study was explained to the school principals and any questions asked were answered by the researcher. Permission to include participants from the schools was obtained from the principals. Where principals agreed to participate in the study, interview dates were set. Learners were selected with the assistance of the grade teacher and dates for data collection set according to the class schedule.
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Parents/guardians were approached through the school with assistance from a staff member. Parents/guardians were contacted telephonically and dates set for the FGD’s. One planned FGD with parents was rescheduled as IDI’s as a suitable date and time for the group of participants could not be reached.
2.2.7. Data Collection
Data were collected at the participants’ most convenient locations which, except for three IDI’s with parents that were conducted at their homes, were conducted at the schools. A study supervisor and a PhD student were present during one and two FGD’s as non-participating observers respectively. The researcher’s occupation and the reasons for the study were discussed with participants as part of the consent process.
The aim of the IDI’s and FGD’s were to elaborate on pre-set main themes and sub-themes that emerged from the data. All IDI’s and FGD’s were conducted by the researcher between March and June 2017. All IDI’s and FGD’s were recorded using a digital voice recorder and then transcribed by the researcher. Extracts of transcriptions are added in Appendix 9. Recordings and transcripts were saved on a password protected laptop which was only accessible by the researcher.
An interview schedule was used to guide the questioning during the IDI’s and FGD’s. Depending on the literacy level of the participants, two different sets of questions with variable wording were used (Appendix 10). The questions were developed from objectives and constructed to be open ended as to avoid biasing the participants’ responses and broadening the scope of information gathered. Questions were also translated into Afrikaans as 47 (87%) of the schools were Afrikaans medium (Appendix 11). The IDI’s and FGD’s were done in the participants’ preferred language. Only one IDI was done in English as
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the participant indicated English as her home language. The questions used were the same for both groups (IDI’s and FGD’s) and the phrase spinal health was defined as “taking care of your back” to all participants:
1. What do you know about spinal health?
2. What type of spinal health education have you been exposed to? 3. What are your feelings towards the spinal health of learners? 4. What do you think the impact of spinal health is on an individual? 5. What do you think signs of poor spinal health are?
6. What do you feel are the facilitators and barriers to good spinal health? 7. What do you think can be done to facilitate with spinal health barriers?
8. What do you think are the most important aspects to be included in good spinal health promotion?
The duration of the sessions ranged from 30 to 60 minutes with only one group session lasting less than 30 minutes. The researcher took notes on the discussion schedule during the interview and discussion sessions. A summary of the discussion sessions was made after each session was concluded and included the session’s characteristics; main themes; surprising information; and new themes not emerging from previous sessions.
Transcripts were not returned to the participants for comments but random transcripts were compared to their recording by an independent researcher to ensure credibility of the data. The study results were returned to random participants for comments. One repeat FGD was conducted with a group of Secondary School learners, within the same community of a group of Primary School learners, after inconsistent data about the influence of violence was obtained from the latter group. The researcher continued to conduct IDI’s and FGD’s until data saturation pertaining to the study objectives were reached.
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2.2.8. Data Analysis
Data analysis was performed only from the transcripts to avoid researcher bias. Inductive reasoning was used to explore the phenomena of spinal health in learners and to then narrow the scope of the study according to the objectives. Inductive reasoning was used due to limited qualitative research in the field and there is no existing model or framework to base the study’s findings on. Each transcript was read multiple times and coded by the researcher according to ten main themes derived from key words in the topic guide questions. Sub-themes were derived from emerging data within the main themes and linking main themes were subsequently grouped into families. The Coding Tree (Appendix 12) depicts the codes used by the researcher. The researcher made use of ATLAS.ti computer software for the coding and data management. The data from the different participant groups (learners, parents/guardians, principals and teachers) were grouped together, analysing each group’s data separately and then combining the data sets to form one collective data set. The principle researcher discussed and reflected on the themes and sub-themes with two co-authors. Transcripts were not translated and remained in their original language as the researcher is equally proficient in both Afrikaans and English. The data analysis was done from these original transcripts.
2.2.9. Trustworthiness
As qualitative research does not make use of established validity and reliability measurements, quality criteria for qualitative research were adhered to during the study process to ensure the trustworthiness of the study. The quality criteria for qualitative research are credibility, transferability, confirmability and dependability. Credibility was ensured by adopting a semi-structured question format which ensured all participants were
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asked the same questions but allowed the researcher leeway to ask further explorative questions on the topics raised. In addition, two data collection methods (IDI’s & FGD’s) were employed to make up for individual shortcomings. By using IDI’s the researcher was able to go into more detail with certain topics with the particular participant. Whereas the FGD’s allowed for participants to comment and elaborate on each other’s thoughts and ideas broadening the perspectives. By using both IDI’s and FGD’s the researcher ensured both narrow and broad investigation of the topics. These steps instil confidence in the researcher that the study’s findings are true and accurate.
The transferability of the study’s findings is not limited to only rural schools as used in the study, but can also be applicable in other contexts. Other contexts could refer to similar situations, populations and phenomena. Other rural schools in South Africa are included in the situations, being the most similar to this study’s situation. The population of this study is similar to the population in South Africa with regards to the age of learners. The study population was sourced from public schools which make up the majority of the schools found in South Africa, therefore making the findings applicable even in different situations. By extension, the phenomena of spinal health in schools can be observed in any school across the globe, making the study’s findings applicable and partially transferable to any other school.
To ensure the confirmability, the study’s methodology is described highlighting the researcher’s neutrality in the findings. The study’s findings are based on the participants’ responses and not from the researcher’s personal motivations and potential bias. Triangulation of data further reduces the effect of researcher bias on the study’s findings.
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Dependability of the study’s findings was ensured by describing the research process and data analysis. By using the same methods in repeat studies, researchers should be able to produce consistent findings. The research process and data analysis was also reviewed externally to ensure consistency of the findings.
2.3. RESULTS
2.3.1. Demographic Data
As depicted in Table 2.2, the demographic data of 93 subjects were captured of which 66 were female and 27 were male participants. In total 9 IDI’s and 11 FGD’s were conducted. Participants identified themselves as white (32%), coloured (57%) or black (11%). The participants spoke in their preferred language, of the 93 participants only one participant spoke English and one participant spoke a mixture of English and Afrikaans while the remaining participants all spoke Afrikaans. Table 2.3 depicts the number of schools and enrolled learners per town region.
Table 2.2: Demographic Data
Participants n(%) Male n(%) Female n(%) F/M Ratio Age range (Mean) No. of IDI/FGD Race White n(%) Coloured n(%) Black n(%) Learners 43 (46) 18 25 1.39 8-22 (14.51) 0/5 8 31 4 Parents/Guardians 17 (18) 1 16 16 27-63 (43.65) 3/2 5 10 2 Principals 4 (4) 2 2 1 41-62 (55.25) 4/0 3 1 0 Teachers 29 (31) 6 23 3.83 22-61 (39.03) 2/4 14 11 4 Total 93 27 (29) 66 (71) 2.44 8-63 (29.24) 9/11 30 (32) 53 (57) 10 (11)
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Table 2.3: District Schools and Learners
Town Schools n(%) Enrolled Learners n(%) Schools Included n(%) A 6 (11.1) 3843 (21.0) 3 (21.4) B 10 (18.5) 2315 (12.6) 1(7.1) C 3 (5.6) 473 (2.6) 1 (7.1) D 16 (29.6) 3106 (16.9) 5 (35.7) E 18 (33.3) 8526 (46.5) 4 (28.6) F 1 (1.9) 62 (0.3) 0 (0.0) 54 18325 14
Five teachers from one group were unable to participate on the set day of the FGD due to changing schedules and personal responsibilities. Two learners were absent on the day of the FGD due to illness and three failed to return their parental consent forms and were subsequently excluded. One group of parents initially selected from a selected school was not willing to participate in the study for reasons unknown to the researcher.
2.3.2. Themes
The IDI’s and FGD’s provided insightful information as participants shared their experiences and ideas. The most relevant themes and sub-themes about the participants’ perceptions are discussed in the sections below followed by supporting quotes. Participant quotes are provided with participant identifiers (gender, age, school type, and participant group). The quotes were translated from Afrikaans to English for this paper by the researcher; back translation was used to ensure that the quotes’ meanings remained the same.
2.3.2.1. Theme 1: Barriers associated with self-care of spinal health
This theme describes factors identified by participants as barriers to spinal health or back care in schools. The sub-themes that emerged from the data, describe specific factors which may bar learners from taking care of their backs. The barriers associated with spinal health
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of learners were multifactorial including sedentary lifestyles, dangerous gameplay, sports’ risks, poor ergonomics, schoolbags, insufficient knowledge and pregnancy risks. Proper school furniture and schoolbags are not in sufficient or affordable supply and decreased activity leads to injuries while doing sport or exercise.
Sedentary lifestyles and bad postural habits of learners
Modern technology and low nutritional diets have greatly contributed to the passivity of learners, with minimal funding, being overweight or tall adding to poor spinal health seen in schools.
Teachers were concerned about the physical strength capabilities of learners due to physical inactivity or passivity at home. This was attributed to the influence of modern technology, with learners mostly watching TV or playing on a cell phone, tablet or computer. Additionally, learners’ ergonomic and postural interaction with technology was worrying.
Interestingly standing out among peers with regards to length was seen as a negative influence on spinal health. Parents stated that overweight learners struggled and complained more about their backs which resulted in them not participating in sports or exercise. It was the belief of teachers that learners’ poor postural control when writing was due to inactivity causing poor muscle tone in the trunk girdle. The costs involved for treatments were considered an obstacle and reason why required treatment was not sought. Concerns regarding insufficient nutrients for healthy physical development in learners and the effect on spinal health were also expressed.
“It worries me. It does worry me because of the inactivity of our children at school.
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strength that our children today have compared to what we had when we were young.” (Female, 61, Secondary School Teacher)
“They sit in front of the TV; they sit and play with a cell phone. I think that back health is in a very bad state in South Africa because of sitting so much and sitting incorrectly.” (Male, 62, Primary School Principal)
“I have a friend whose daughter is overweight and she complains about her back a lot and then she doesn’t want to do sport.” (Female, 49, Secondary School Parent) “Children who are tall have the problem that they want to be short, they want to be like other children, and then they bend their backs the whole time.” (Female, 11,
Primary School Learner)
“Children don’t play and develop those muscles so they have low muscle tone in the trunk area and then they can’t sit and write properly.” (Female, 44, Intermediate
School Teacher)
“The vast majority of children that have problems don’t have the funds to receive therapy.” (Female, 42, Primary School Principals)
“If you don’t get the right nutrients, sufficient nutrients, then your skeleton is going to develop poorer.” (Female, 42, Primary and Secondary School Parent)
Dangerous gameplay of children
Rough play is seen as the norm with children ignoring their parents’ warnings.
Participants expressed concern about the rough and, sometimes, aggressive nature in which learners played. Teachers saw rough play as bullying and attributed this behaviour to what learners were exposed to at home or maybe within their environments. Learners seemed to model older children and they were influenced by what they saw on television. Parents added that their children didn’t heed warnings about how they played and reported that they responded in anger when children were injured while playing.
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“They play rough at school. They strike each other. They are wild. They wrestle and everything.” (Female, 54, Primary School Parent)
“They wrestle. If something is fun then they (children) do it in any case.” (Female, 43,
Secondary School Parent)
“Children do what they see at home. They would kick and choke others, that’s not playing, they’re bullies.” (Female, 58, Primary School Principal)
“Children from being, playing wild. You just told them then they run around doing it again. Go complain there where you got injured!” (Female, 34, Primary School
Parent)
Sports’ injury risks
Lack of education on the part of the teachers (coaches), insufficient warm-ups, unfit learners and very vigorous sports are contributors to back problems. Learners also play sports while injured so as not to be left out.
Learners commented that due to their nature, sports like rugby, hockey, netball and cricket could lead to back injuries. Learners expressed that being unfit, improper warm-ups before matches and coaches with questionable competency could increase their risk of injury or back pain. Although learners expressed their belief that even though participating in sports is not always beneficial for them (due to e.g. illness), they would not stop their participation. Parents’ belief was that learners wanted to “belong and be a part of something” which resulted in sport participation while injured instead of recovering. Parents attributed the injuries sustained by learners to insufficient and improper warm-ups before matches, with learners admitting to lying to their coaches about doing sufficient warm ups. Teachers expressed their concern in their own abilities to coach sports and stated that smaller schools
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expected all staff members to coach sports, irrespective of whether they had received any training.
“They play hard, then they get tackles hard or when you are in the ruck and everyone dives at you.” (Female, 19, Secondary School Learner)
“If you have to bowl for long, then it (back) is sore, but I just carry on.” (Male, 11,
Primary School Learner)
“Children are unfit. Then you have to play all those matches.” (Male, 17, Secondary
School Learner)
“No, it probably isn’t always good, but I’m not going to stop, I enjoy it.” (Male, 18,
Secondary School Learner)
“They don’t warm up right, it’s not good enough. You have to be warm, your muscles. That’s why he got injured.” (Male, 62, Secondary School Parent)
“The coach isn’t always there, then you don’t feel like warming up.” (Male, 18,
Secondary School Learner)
“I have to coach shot-put, I look like I can do shot-put, but I never did. I can do something wrong. We don’t have outside coaches like the big schools.” (Female, 33,
Primary School Teacher)
Poor furniture ergonomics in the classroom
Incorrectly sized or broken school furniture, together with long periods of sitting still, is not beneficial to good spinal health.
Participants were concerned with the length of time learners had to sit in classrooms as it reportedly influenced the spinal health as learners made use of awkward adaptive postures. The type of chair or desk and the anthropometric fit thereof to learners was identified as noteworthy furniture considerations for spinal health. Learners and parents especially
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expressed concern about the quality of the school furniture and the impact it might have on spinal health. Additionally, classroom layout was nominated as a consideration to improve the ergonomic practice in the classroom.
“My problem is children that sit too long and continuously sit in classes.” (Male, 62,
Primary School Principal)
“My back gets sore if I sit for too long in one position.” (Female, 11, Primary School
Learner)
“Sometimes you get, then it doesn’t feel right to you because you sit too long. And then your back or your butt gets stiff. Then it feels like you can’t move.” (Female, 22,
Secondary School Learner)
“These school desks are a lot of trouble to sit in, I can’t sit up straight, I slouch. And
when I’m tired I slouch more. I feel it when I play piano too.” (Female, 18, Combined
School Learner)
“Sometimes I move down to rest with my head on the desk behind me, just to relax,
then my neck gets sore.” (Female, 18, Secondary School Learner)
“The laboratory stools, they can’t be good for the children. I think, I don’t know, maybe.” (Male, 27, Intermediate School Teacher)
“There’s no back support, it (laboratory stool) is good for your abdominal muscles, but bad for your back.” (Female, 17, Combined School Learner)
“The stool is high and the table not, then you have to write like this, you have to bend down to the table.” (Male, 19, Secondary School Learner)
“These things, the wood, what’s it called, backrest is hard, I don’t like sitting against it.” (Female, 18, Combined School Learner)
“Some of the desks, then it is just the iron at the back. And some people will lie against that iron, later in the day they can’t stand up.” (Male, 20, Secondary School
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The school desks don’t comply with standards according to me. At parent’s evenings I try to get into those things and there’s no way, the bench is short, it doesn’t support your thigh. And there are children who are bigger than me at school.” (Male, 62,
Secondary School Parent)
“If the desks are turned towards each other and the teacher doesn’t even have a central point from where the class is taught, then you get that the children have to turn around.” (Male, 62, Primary School Principal)
School bag types, weight and carrying methods
The importance of the type, weight and the way schoolbags are carried is not emphasised enough. Financial restraints also lend themselves to the learners not having the correct bags.
Participants stated that learners were required to carry many heavy textbooks every day in their schoolbags. Parents stated that there were no schoolbags on the market rated for the weight that learners needed to carry. Teachers said that learners carried all the textbooks in their schoolbags every day as they were afraid that they would forget some of them. Participants said that learners carried their schoolbags incorrectly, either just on one shoulder or hanging very low on their backs, in order to look ‘cool’. Learners admitted that these statements were true and added that the forward leaning posture caused by carrying bags over both shoulders to counteract the weight of the bags, looked wrong. Furthermore, learners said that it was quicker to sling their bags over one shoulder. Parents stated that they were more concerned about the way in which the learners were picking up their bags than how they were carrying them, as learners were usually bent and rotated when picking up their bags.
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Principals acknowledged that, due to the low socio-economic status of many households in the school districts, the type of schoolbags that should be used by the learners could not be prescribed. The low socio-economic status was also the reason why some learners carried their textbooks in plastic shopping bags. It was the belief of principals that the soft backpacks used by many learners were not properly supportive of the learners’ backs. Learners, however, stated that the soft backpacks were more comfortable to carry and that stress increased the discomfort of carrying a heavy schoolbag. Principals were concerned about the manner in which learners pulled wheeled schoolbags, stating that when the wheels caught on an obstacle, it caused the learners’ rotated backs to be jerked.
“The children’s bags are really heavy with all the textbooks they have to carry.”
(Female, 32, Primary School Teacher)
“Heavy suitcases are carried incorrectly.” (Male, 60, Combined School Principal) “It doesn’t look right when you lean forward like that because of your bag.” (Female,
17, Combined School Learner)
“It’s quicker. If I put my bag properly over both shoulders then by the time I’m done, they are in the next class already.” (Male, 18, Combined School Learner)
“The little ones when they start here in grade 4 with textbooks, it’s pretty difficult for them sometimes, they forget their things. So lots are afraid, then they carry everything in their bag and that’s how they go to school every day.” (Female, 31,
Primary School Teacher)
“But I don’t worry how he puts it (schoolbag) on (his back).” (Female, 63, Primary
School Grandparent)
“When they pick up their bags, I don’t know how you did it, but they stand in their desk then turn and bend to pick up the bag next to then. That’s the big problem with the heavy schoolbags.” (Male, 62, Primary and Secondary School Parent)
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“Those backpacks they carry are soft and flimsy, they don’t protect the textbooks or the children’s backs, but they’re cheap. Remember the people in the district are poor. So we can’t tell them what schoolbag they have to buy, we can advise them. And I tell the board every year they can’t when they want to make a rule about the schoolbags.” (Male, 60, Combined School Principals)
“I had one of those student bags with the rigid stuff, but I didn’t like it. My backpack feels better, the padding is more comfortable on my shoulders and back.” (Male, 17,
Combined School Learner)
“Children carry their (school) books in plastic shopping bags.” (Female, 58, Primary
School Principal)
“When you stress it sits in your shoulders, it hurts, your bag is heavier.” (Female, 19,
Secondary School Learner)
“When they pull those bags, the one with the wheels, those wheels are small, they pull the bag behind them with their backs turned slightly. Then the wheels catch and it jerks them. That can’t be good for their back.” (Male, 62, Primary School Principal) Teachers’ unknowing negative impact on learners’ spinal health
Teachers and Life Orientation (subject) are not properly equipped to encourage spinal health in learners.
Teachers stated that they didn’t actively think about the wellness of learners’ backs and admitted that they unknowingly might have been doing things that were harmful to learners’ backs. Teachers said that they were hurried to complete their work and either forgot or didn’t allow the learners to have breaks during class to stretch their backs. It was the belief of principals that Life Orientation, the one subject that should address the wellbeing of learners, was not being managed optimally and that physical education was too generalised. Principals stated that those who had the power within the school system were
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uneducated on spinal health and therefore didn’t have the knowledge to address potential issues, unless they personally suffered with back problems.
“It’s not like you think of their back every time you do something. So perhaps we could be doing stuff that’s not good for their backs.” (Female, 29, Intermediate
School Teacher)
“You are in such a hurry to finish your work, you don’t have enough time. Then you forget about these strategies like the stretching to help you.” (Female, 25, Primary
School Teacher)
“When you look at Life Orientation, the exercises are not specific to help with the back or sitting and such. Life Orientation should be the most important subject that prepares children for life after school. But that’s not how it is.” (Male, 60, Combined
School Principal)
“The teachers aren’t taught about spinal health and what’s good for children and bad. Then they become principal and have to make decisions that influence children. I have an idea because I have a back problem and I’m aware of it.” (Male, 60,
Combined School Principal)
Learners’ insufficient knowledge about spinal health
Learners are not sufficiently educated as to the importance of spinal health, which leads to misconceptions. Teachers and parents have difficulty in accommodating the abundance of information and thus spinal health is not addressed by them.
Learners admitted that neither they nor their teachers or parents had sufficient knowledge regarding proper back care, with the adults also sitting incorrectly. Learners stated that if they do not currently experience back pain, they didn’t think about their backs. They also stated that they didn’t think of the future in relation to their backs as they lived in the here and now. This was why the importance of spinal health was difficult to comprehend.
